Enhancing emotion regulation

ABSTRACT

Background: Emotion regulation (ER) refers to the process of modulating an affective experience or response. Objectives: This is a systematic review of the research on therapist methods to facilitate patient ER, including affect-focused, experiential methods that aim to enhance immediate patient emotion regulation, and structured psychoeducation, skills training in ER. Method: A total of 10 studies of immediate and intermediate outcomes of emotion regulation methods were examined. A total of 38 studies were included in the meta-analysis of distal treatment effects on emotion regulation. Results: In eight studies with 84 clients and 33 therapists, we found evidence of positive intermediate outcomes for affect-focused therapist methods and interpretations. A meta-analysis of 26 studies showed that the average effect size of ER methods from pre- to post-treatment was large (g = 0.82). Conclusions: Both affect-focused and structured skill training are associated with distal improvements in emotion regulation. When working with ER in psychotherapy, therapists must consider how patients’ cultural backgrounds inform display rules, as well as what might be considered adaptive or maladaptive. The article concludes with training implications and therapeutic practices based on the research evidence.

Keywords:

• psychotherapy methods
• emotion regulation
• affect-focused therapies
• emotional awareness
• experiential avoidance
• psychotherapy
• psychotherapy outcome
• meta-analysis

Clinical Impact Statement

• Enhancing patient emotional regulation capacity is therapeutic for a variety of behavioral disorders.

• Therapists may use either affect-oriented methods or structured psychoeducational and skill training methods to work with emotion regulation.

• Therapist in-session methods aimed at undoing experiential avoidance, enhancing emotional awareness, promoting a full emotional experience, and teaching strategies to cope with distress may be effective in facilitating in-session emotion regulation.

Emotion dysregulation is considered one of the common core mechanisms of psychopathology (Gratz et al., 2015) and is an emerging transdiagnostic focus of psychotherapy for a wide range of behavioral disorders. Frequent methods of enhancing patient emotion regulation across a variety of treatment packages include: (a) undoing avoidance of negative emotions, (b) enhancing emotional awareness, (c) allowing the full experience of feared or avoided emotion, (d) learning effective cognitive reappraisal, and (e) learning behavioral and action strategies to modulate unpleasant emotions (Berking et al., 2008; McMain et al., 2010).

Psychotherapies that address emotion regulation can be roughly divided into two groups. The first group consists of structured psychoeducation and emotion regulation skills training rooted in the cognitive behavioral tradition. These include the unified protocol (UP; Barlow et al., 2017), acceptance-and commitment therapy (ACT; Hayes, 2004), dialectical-behavior therapy (DBT; Linehan, 1993), and mindfulness-based cognitive therapy (MBCT; Segal et al., 2002). The methods developed specifically to address emotion regulation skills include skills training in affect and interpersonal regulation (STAIR; Cloitre et al., 2002), acceptance-based behavioral therapy (ABBT; Roemer et al., 2008), emotion regulation therapy (ERT; Mennin et al., 2015; Renna et al., 2017), and affect regulation training (ATR: Berking & Lukas, 2015).

The second group of psychotherapies is affect-focused, experiential treatments that aim to facilitate immediate patient ER, most often used in affect-focused therapies. These include emotion-focused therapy (EFT; Greenberg, 2021), accelerated experiential dynamic psychotherapy (AEDP; Fosha, 2021), affect phobia therapy (McCullough et al., 2003), and intensive short-term dynamic psychotherapy (ISTDP: Abbass, 2015; Frederickson et al., 2018). The therapist helps patients tolerate and regulate maladaptive emotions and transform them by facilitating the experience of adaptive emotions (Greenberg, 2021), ultimately resulting in decreased emotional arousal and greater calmness and wellbeing (Fosha, 2021).

Although these approaches have somewhat different therapeutic foci reflecting respective underlying theories of emotion regulation, they nonetheless address patient emotion regulation as one of the central targets of psychotherapy. In the structured methods, modules address each of the above emotion regulation components and progressively build emotion regulation capacities. In affect-focused methods, therapists try to be responsive to the patient’s immediate emotional experiencing in selecting an optimally facilitative method.

Definitions and Clinical Description

Emotion regulation (ER) refers to the process of modulating one or more aspects of an emotional experience or response (Gross, 1998). Regulated emotion keeps the individual within a window of tolerance in which optimal emotional functioning is possible (Greenberg, 2021; Siegel, 1999). Emotion regulation is considered to be intrinsic to mental health and adaptive psychological functioning.

ER involves both internal and external actions to initiate, increase, maintain, decrease, or transform both positive and negative emotions in response to changing demands of emotion-evoking situations. Although often used to refer to a person’s behaviors undertaken once distressing emotions have occurred, ER also includes emotion generation, which is how emotion occurs (e.g., Campos et al., 2004). Thus, therapeutic work is not only about teaching strategies to cope with emotions that have already occurred but about transforming those aversive emotions so that more adaptive emotions are experienced in their place (Greenberg, 2021).

There is no singular therapist method directly associated with enhancing patient ER. Therefore, enhancing ER can be defined as a group of therapist methods and responses designed to build and strengthen patient emotion regulation capacity. That can be accomplished through a variety of means: providing relational and dyadic responses, facilitating emotional processing and transformation, and teaching skills for tolerating distressing emotions.

Given that most people seeking psychotherapy have difficulties regulating emotions, facilitating effective ER is a common goal across psychotherapies (Leahy et al., 2011). Reviewing the clinical literature on emotion processing and regulation, McMain and associates (2010) detailed eight common principles: (a) engage in an ongoing assessment of patient’s capacity to modulate emotions; (b) develop a compassionate, accepting, and genuine therapeutic relationship; (c) educate patients about emotions and their function; (d) promote awareness and acceptance; (e) help patients reduce problematic avoidance and inhibition of emotions; (f) increase the capacity to adaptively express emotion; (g) increase positive emotional experiences; and (h) facilitate changes in emotional processes by providing opportunities for new experiences.

Structured Approaches

Structured methods frequently address ER skills by means of psychoeducation, skills training, and homework exercises. The outline of each session typically includes specific tasks to be completed with accompanying workbooks that patients use for homework.

The Unified Protocol (UP; Barlow et al., 2017; Farchione et al., 2021) teaches ER skills in 10–20 sessions of individual treatment. Four modules specifically target ER: (a) psychoeducation about the nature and function of emotions, including a detailed discussion of how the patient’s avoidance of emotion is problematic as it reduces the emotion in the short term but reinforces the cycle of emotions in the long term; (b) teaching patients to observe, name, and let go of their emotions without evaluation; (c) learning cognitive emotion regulation strategies to change misappraisals related to negative emotions; and (d) modifying emotionally driven behaviors, which are a specific set of reactive behaviors associated with emotion to drive a person to withdraw, avoid, and escape with exposure to feared emotions.

In dialectical behavior therapy (DBT; Linehan, 2015), the enhancement of ER is guided by three basic principles (McMain et al., 2001): (a) enhancing the ability to be aware of and accept emotional experience, (b) cultivating the ability to regulate emotions and tolerate distress, and (c) changing negative emotions through new learning experiences with exposure. DBT differentiates distress tolerance skills from ER skills. The goal of distress skills is to accept overwhelming emotions and survive through the crises by distracting themselves with pleasurable and self-soothing activities, but not to effect and change their environment as is the aim of ER skills. Mindfulness skills play a central role in both ER and distress tolerance skill learning. Patients learn to nonjudgmentally observe and describe the present moment through contemplative practice and develop wise mind, which is finding a middle path integrating their reason and emotion (Linehan, 2015).

In the first phase of emotion regulation therapy (ERT; Mennin et al., 2015; Renna et al., 2017), the therapist helps the patient cultivate mindful ER skills to increase awareness of emotional experiences, and act flexibly to the intense emotional experiences. They then teach meta-cognitive regulation skills, such as decentering, reframing, and distancing to create a healthy distance and emotional clarity rather than being reactive and consumed by emotions. The therapist also uses a series of imagery exercises to have the patient vividly remember and experience triggers of their emotional response and facilitate “Do-Overs” in which the patient elaborates and enacts a sequence of more adaptive responses in the session. Patients are also taught breathing and other relaxation techniques. In the second phase, therapists teach patients to adopt a proactive orientation, consciously choosing to exposing themselves to anxiety-provoking, yet rewarding experiences to replace dysregulating patterns. The therapist also uses imaginal exposure and chair dialogue to rehearse taking actions toward their personal values rather than responding reactively through worry and rumination.

Affect-Focused Therapies

ER is enhanced in affect-focused therapies by accessing and facilitating the experience of adaptive emotion whose experience has been previously inaccessible, blocked, or avoided (Greenberg, 2021). The therapist’s consistent empathy, warmth, and validation, even in the face of patient’s feeling upset or overwhelmed, is important because it is internalized by the patient and becomes a part of the way the patient subsequently responds to upsetting events. In addition, the moment-to-moment empathic attunement to the patient’s emotional state creates a clear focus on the patient’s here-and-now experiences as well as ongoing assessment of emotional processing. Therapists also help patients pay attention to physical signs of emotions from changes in breathing, muscular tension, and other nonverbal signs, staying with and absorbing/taking in such experiences, and symbolizing or finding words to describe them.

In addition, therapists facilitate the experience of adaptive emotions through various expressive and evocative techniques (Medley, 2021). The therapist encourages the patient to stay with the emerging emotional experience, sometimes exaggerating and repeating certain actions or phrases so that these are vividly experienced. Dysregulated emotions are transformed by a new experience of adaptive emotions, which Greenberg (2021) called “changing emotion with emotion.” The experience of adaptive emotions is followed by a reflective process of creating its new meaning. Therapists may also help patients reflect the relational experience of being accompanied by the therapist who bears witness to the transformation (Fosha, 2001).

Assessment

Assessing ER Methods

We know of no specific measures of ER methods. Early psychotherapy process researchers identified affect-focused therapist responses using categories of therapist verbal responses (Elliott et al., 1987), such as the revised Hill Counselor Verbal Response Modes Category System (Hill, 1985, 1986). These studies differentiate therapist responses that were facilitative of patient affect such as reflection and minimum encourager from those that were not directly related to facilitation of affect such as provision of information, direct guidance, and advice-giving.

Three rating scales used by trained judges include items that evaluate the extent of affect focus and some aspects of therapist methods for ER. For example, the Psychotherapy Process Q-set (Jones et al., 1988) has items such as, “Therapist draws attention to patient’s non-verbal behavior.” The Comparative Psychotherapy Process Scale (Hilsenroth et al., 2005) includes items such as, “Therapist encourages patient to experience and express feelings in the session.” The Multitheoretical List of Interventions-30 (Solomonov et al., 2019) includes items that identify and label emotions, defenses, conflict splits, moment-to-moment experience, exploring personal meaning, and showing interest in patient’s experience.

Fosha et al. (2018) developed the AEDP 9 + 1 Change Process Scale, a therapist-rated measure of therapeutic methods used in AEDP. Five of the nine items (facilitating access to the bodily-rooted experience and to the felt sense of experience, defense work, experientially processing core affective experience, metatherapeutic processing of transformational experience, promoting integration and processing core state experience) relate to facilitating patient emotional process. One item relates to responding to in-session emotion dysregulation (working with overwhelming and highly distressing emotions and alleviating these emotions within the window of tolerance).

Assessing Outcomes of ER Work

Several observer-rated scales measure in-session behavioral indications of ER. Adequate interrater agreement or reliability have been demonstrated for all of them. The Observer-Measure of Affect Regulation (Watson et al., 2011) defines emotion regulation as consisting of level of awareness/labeling, modulation and arousal, modulation of expression, acceptance of affective experience, and reflection on experience. The Client Emotional Productivity Scale-Revised (Auszra et al., 2013) measures the degree to which a patient experiencing a primary emotion in an effective and useful manner (attending, symbolization, congruence, acceptance, regulation, agency, and differentiation). The Classification of Affective-Meaning State (Pascual-Leone & Greenberg, 2005) classifies patient emotional state into specific types of primary or secondary emotions based on vocal tone, involvement, and meaning. The Achievement of Therapeutic Objectives Scale (Berggraf et al., 2012) includes a subscale of Activating Affects, and the Client Expressed Emotional Arousal Scale-III-R (Machado et al., 1999) measures expressed emotions in terms of its intensity and type (anger, fear, joy, love, sadness, and surprise) based on the vocal quality and nonverbal behaviors.

In addition, there are a number of self-report measures of ER that would typically be completed by patients’ post-session; adequate reliabilities and validities have been reported for all. These include: Emotion Regulation Questionnaire (Gross & John, 2003), Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004), Emotion Dysregulation Questionnaire (Gill et al., 2021), Action and Acceptance Questionnaire-II (Bond et al., 2011), Affective Style Questionnaire (Hofmann & Kashdan, 2010), Emotion Regulation Skills Questionnaire (Berking & Znoj, 2008), Cognitive Emotion Regulation Questionnaire (Garnefski et al., 2001), Affect Integration Inventory (Solbakken et al., 2011), Distress Tolerance Scale (Simons & Gaher, 2005), Meta-emotion Scale (Mitmansgruber et al., 2008), Emotional Processing Difficulties Scale-Revised (Faustino et al., 2022), Emotion Regulation Goals Scale (Brandão et al., 2022), and Dimensions of Openness to Emotions (Reicherts, 2007). Several scales tapping common positive and negative emotions are also sometimes used as client self-report measures of emotion regulation: The Positive and Negative Affect Schedule (Watson et al., 1988) and Profiles of Mood State Questionnaires (Mcnair et al., 1971). In addition, the Self-Compassion Scale (Neff, 2003) measures how individuals respond to emotionally distressing events.

Zelkowitz and Cole (2016) examined convergent and discriminant validity of eight self-report emotion regulation scales with a large university student sample. Exploratory factor analysis revealed three factors: out-of-control negative emotions representing the degree to which a person experiences strong negative emotions that are beyond one’s ability to regulate; emotional awareness and expression representing the degree to which individuals are aware of, admit to, and express strong pro-social emotions ranging from joy to guilt; and cognitive strategies for emotion regulation, reflecting concrete cognitive strategies for regulating negative emotion such as positive reappraisal, refocusing on planning, and putting into perspective.

Clinical Examples

In the following, we present three examples of working with emotional regulation. All three are within the context of psychotherapy practice from the United States with experienced therapists of each orientation.

AEDP Methods for Working with Dysregulated Emotions

The first example is taken from Lamagna (2021) who illustrates the work with emotion dysregulation in AEDP. A married white female patient in a late middle age (P) on the verge of leaving her husband was flooded with distressing emotions.¹ The therapist is an experienced AEDP white male therapist.

P:

(Getting more distressed) It just hurts so much. (tears up) It’s still so close — that feeling . . . (pause) and I feel afraid of it.

T:

Yes. Let me help you with that feeling.

P:

I don't know what I'm feeling. It's too hard for me (increasingly agitated, gasping with tears in her eyes).

T:

Linda . . . can you just check in with me for a second? Can you feel me here with you?

P:

[Not registering the therapist’s statement] It all hurts too much. I miss my mother. (breaks into sobs).

T:

(Softly) Yes.

P:

(Sobbing) I missed so much.

T:

(Slowly and with softness) Yeah, you did. Keep breathing.

P:

I keep telling myself I'm doing well. I have this wonderful world around me . . . (sobs)

T:

Can you check in and see that I'm here with you? See if we can ask this distressed part of you if she would be willing to separate out —- just a little bit. And if she won’t, it's okay. We'll figure out other ways of helping.

P:

I’m just surprised it's so deep.

T:

Okay. Do you have a sense whether there is a willingness for the distress to step back? Did you feel any shifting in your body?

P:

I’m just able to breathe. (Seems slightly calmer)

Th:

Just notice that you can breathe now. (long pause) What are you noticing now?

The therapist first responded with calling attention to his empathic presence, using a gentle tone and slowed-down speech, to dyadically regulate the patient’s dysregulation that exacerbated her sense of aloneness. Then he used physical regulation (breathing) to help the patient attend to and accept the somatic experience of her emotion, to which the patient responded partially. The therapist also used intra-relational method which asked the patient to separate from the distressed part of herself. The patient finally made a meaningful contact with the therapist and partially regulated her distressing emotion.

Affect-oriented Methods for Enhancing Emotional Awareness

In the following vignette (from Paivio & Pascual-Leone, 2010), a young adult male patient, who had complex PTSD, felt he could never rely on others for support.² Acknowledging his emerging sense of insecurity and neediness was uncomfortable and made him uneasy. The experienced middle-age white therapist oriented the patient’s attention to emergent feelings and aimed to help him allow the emotional experience and increase his emotional awareness.

T:

So, it’s about feeling alone, that’s the main concern, like you can’t handle it?

P:

It’s not, “can’t handle it,” exactly, but … lonely. I hate it.

T:

OK, stay with that lonely feeling. It’s uncomfortable, I know, but let’s explore it a bit.

P:

Like, I hate coming home from work, the apartment is so empty, we used to talk about stuff. She always seemed to understand, well, at least listen (laughs) … Like now I‘m just floundering around … 

T:

Floundering, directionless. So, she was like your anchor, it’s like you were so very attached to her.

P:

Yes, I guess I was.

T:

And now she’s gone, you’ve become unattached, not only lonely but kind of insecure?

P:

Yes, I do feel insecure, less confident, it’s weird. I never realized how much I depend on her.

T:

Say more, depended on her for what?

In the above vignette, the therapist uses empathic responding to help the patient explore the nuance of the patient’s subjective emotional experience; as a result, the patient learns to differentiate his lonely feeling to enhance a sense of emotional clarity.

UP Methods for Addressing Emotional Avoidance

The third example, taken from the UP for emotional disorders by Barlow et al. (2018), addresses patient’s emotional avoidance and concerns about being more in the present with her emotional experiences in the module of mindful emotional awareness. The therapist is a middle age experienced white male, while the patient is a young adult white female.

P:

I don’t like to sit still— it makes me more anxious.

T:

Tell me more— what happens when you sit still?

P:

I don’t know— I just feel like I should be doing something. I feel like if I stop thinking about everything I need to do, my whole day will fall apart. I’m also afraid I’ll start thinking about things I’d really rather not think about.

T:

So by sitting still and focusing on the present, you’re afraid you will be losing control of things that are supposed to happen today and that you might start thinking about things that have happened in the past?

P:

Yeah, and that just makes me even more anxious.

T:

So, you are not late for anything at the moment, but you are focusing on the possibility that

 

you might be late later on. How does focusing on the possibility you might be late later on make you feel?

P:

Anxious!

T:

And what about the information that right now, in this moment, you are not running late?

P:

Well, much less anxious. But I still could run late later!

T:

The thing is, you have no way of knowing exactly what may happen later. You may hit traffic or your doctor’s appointment might run over. Or, alternatively, you might find the roads are clear and your appointment only lasts 15 minutes instead of the scheduled 30 minutes. In other words, you just don’t know. The only thing you do know for sure is that you are in this office right now, and at the moment you are not late for anything. This means that the only thing that is different about worrying about the future as opposed to paying attention to the present moment is that one makes you really anxious and the other makes you less anxious.

In this excerpt, the therapist uses a psychoeducational approach to help the patient focus on the present rather than worrying about the future. He thus tried to help her modulate her anxiety by differentiating the anxious thoughts from the external reality.

Previous Reviews

Sloan and associates (2017) identified 67 studies that measured changes in both emotion regulation and psychopathology following a psychological treatment, both individual and group. The treatments examined included affect-focused therapies such as EFT and STDP, as well as structured therapies such as ACT, CBT, DBT, EMT, and MBCT. Both maladaptive emotion regulation strategies and overall emotion dysregulation significantly decreased at post-treatment in all but two studies regardless of (a) specific treatment, (b) the measure of emotion regulation, and (c) the patient’s disorder.

Moltrecht and colleagues (2021) examined 21 RCTs of psychological treatments for improving ER in youth (from ages 6–24). These treatments improved patients’ ER, which in turn was associated with the improvements in psychopathology, but effect sizes were small.

A meta-analysis by Daros et al. (2021) included 90 RCTS on treating depression and anxiety among patients aged from 14 to 24. Treatments included a variety of cognitive-behavioral therapies, such as ACT, CBT, and DBT, as well as ERT. Patients’ ER skills significantly improved, which was positively related to improvements in their depression and anxiety.

In sum, these meta-analyses generally showed the positive effect of structured treatment packages on ER. They did not, however, review the specific components of treatments associated with the changes in ER.

Research Review

Search Strategy and Inclusion Criteria

We searched PUBMED, PsycINFO, and Web of Science between August 2021 and May 2022 using the following terms: counseling or therapy, therapist response, therapist interventions, therapist strategies, emotion regulation, emotional experience, outcome, and emotional expression. We also asked colleagues for articles that might have been missed in the search.

The following inclusion criteria were set: (a) actual individual psychotherapy studies (no analogues), (b) published in English, (c) included actual adult patients (age 18 or over) with psychological problems, (d) included at least one validated self-report or observational measure of ER, (e) included a measure of immediate, intermediate, or distal outcome. Studies were excluded if (a) the treatment was predominantly given in a group format or in an e-learning format; (b) they consisted of analog sessions with those within a normative population; and (c) the studies did not report sufficient data on above inclusion criteria (e.g., pre- and post-treatment means, SDs, sample sizes) or obvious errors in these values were found (e.g., unusually large effect sizes).

Identified publications were downloaded from the databases. If relevant literature was identified during the abstract screening, we manually screened their reference lists for further eligible publications. The selected studies were appraised independently by the first two authors for methodological aspects, such as sampling and sample characteristics according to our inclusion and exclusion criteria. The two authors discussed and came to agreement when the eligibility of a study was unclear. The final list was examined by the third author.

The flow chart provides an overview of the extraction procedure (Figure 1). The initial web search identified 743 articles. We added 64 additional records identified from previous meta-analyses. From a total of 807 studies, 763 articles were excluded based on the abstract and method screening. An effectiveness study on AEDP (Iwakabe et al., 2022) was added because it included an ER measure. In total, 44 studies entered the full text screening. Of these, 13 papers had to be excluded due to insufficient data reported. Thirty-one studies matched the selection criteria and provided sufficient data. During the data extraction, three studies were excluded because some values were clearly wrong (e.g., effect size d > 3.0).

Figure 1. Flow diagram of the study selection process.

ER and Immediate and Intermediate Outcomes

We first reviewed the literature on immediate and intermediate in-session treatment outcomes. Immediate outcomes were typically assessed in the subsequent speaking turn or the same segment of a session in which a therapist method was used. Intermediate outcomes were assessed with self-report ER questionnaires administered at post session after a particular intervention module such as emotional awareness skills module was used.

Table I summarizes a total of eight studies (84 clients and 33 therapists) of ER in association with immediate in-session outcomes and two studies (14 clients and 2 therapists) of intermediate outcomes. Most studies were multiple case studies, and one was a qualitative study. Given the small number of studies, we could not conduct a meta-analysis. Instead, we used box scores (our judgment based on the evidence of the outcomes) to aggregate the effects of ER methods across studies.

Table I. Studies of immediate and intermediate outcomes of emotion regulation methods.

Study	Sample	Measures of ASR, Outcomes, Moderators	Results
Stalikas and Fitzpatrick (1996)	3 archival single sessions with 3 clients all from the U.S., and 1 RET, 1 client-centered, 1 gestalt therapist who is from South Africa.	Measure of Therapist: HCVRCS-R (Friedlander, 1982) as coded by trained judges from transcripts. 8 categories were collapsed into three categories in terms of degree of structure. Measure of immediate in-session outcome: Experiencing scale (Klein et al., 1986) rated by trained judges using a 7-point scale (1 = impersonal, avoided, 7 = feelings are attended to and used for problem resolution and self-understanding)	Intermediate Outcomes No relation was significant between degrees of structure of therapist responses and experiencing (= box score).
Gazzola and Stalikas (1997)	6 single Sessions conducted by Carl Rogers 2 male and 4 female clients, all apparently from the U.S.	Measure of Therapist: The category of Interpretation in HCVRCS-R (Friedlander, 1982) as coded by trained judges from transcripts: Consensual qualitative research. A group of three judges independently described in writing about the nature of interpretation, the manner in which it was delivered, and the client immediate reactions following interpretation. Measure of immediate in-session outcome: The Experiencing scale (Klein et al., 1986) rated by trained judges using a 7-point scale (1 = impersonal, avoided, 7 = feelings are attended to and used for problem resolution and self-understanding)	Immediate In-Session Outcomes Interpretations occurred 17 times and in 13 times they were followed by the occurrence of a higher experiencing (+ box score) Interpretations that were followed by client experiencing: (a) referred to specific client feelings, (b) were phrased tentatively, (c) delivered using the voice of the client, and (d) addressed immediate feelings.
Hill et al. (1988)	Eight case studies of 12-session courses of psychotherapy in the U.S. The 8 clients were adult and female and were depressed, anxious, and had self-esteem and relationship problems. The experienced therapists (4 male, 4 female, all White) came from a range of theoretical orientations.	Measure of Therapist Method: HCVRCS (Hill, 1985, 1986) as coded by trained judges from transcripts which has 8 categories: approval, information, direct, guidance, closed question, open question, paraphrase, interpretation, confrontation, and self-disclosure. Measure of immediate in-session outcome: Client Experiencing scale (Klein et al., 1986) rated by trained judges using a 7-point scale (1 = impersonal, avoided, 7 = feelings are attended to and used for problem resolution and self-understanding)	Immediate In-Session Outcomes Ratings of client experiencing following speaking turns that included therapist self-disclosure averaged 2.49 (SD = 0.73) on a 7-point scale (7 = high) (+ box score). Followed by open question (m = 2.40, SD = .65), approval (m = 2.36, SD = .65), Paraphrase (m = 2.34, SD = .65) and interpretation (m = 2.34, SD = .67). (= box score for interpretation)
Silberschatz et al. (1986)	Three adult patients with good, moderate, and poor outcome in a 16-session individual psychotherapy from the Mount Zion Brief Therapy Research Project. Therapists were experienced psychodynamic therapists. A multiple case study	Measure of Therapist Method: Transference interpretations were classified using the Malan intervention typology defined as any interpretation directed toward the patient’s feelings about the therapist or the therapy. Plan compatibility of intervention scale was used to measure the extent to which a therapist response is suited to case formulation of the patient’s plan on a 7-point Likert scale as coded by trained judges from audiotapes and transcripts. Measure of immediate in-session outcome: Client Experiencing scale (Klein et al., 1986) rated by trained judges using a 7-point scale (1 = impersonal, avoided, 7 = feelings are attended to and used for problem resolution and self-understanding)	Immediate In-Session Outcome The degree to which the therapist passed tests was significantly and positively related to the client experiencing immediately following the therapist statement in both cases. (+ box score for plan compatible interpretation)
Silberschatz and Curtis (1993)	Two adult patients with dysthymic disorder in a 16-session individual psychotherapy from the Mount Zion Brief Therapy Research Project. Therapists were experienced psychodynamic therapists. Both had an excellent outcome. A multiple case study	Measure of therapist method: Patient test scale was used to identify segments of patient’s testing the therapist. Patient test scale was used to identify segments which had included testing of a central pathogenic beliefs in the therapeutic relationship. Therapist Scale was then used to rate the extent to which the therapist passed or failed the patient’s test on a 7-point Likert scale. Measure of immediate in-session outcome: Client Experiencing scale (Klein et al., 1986) rated by trained judges using a 7-point scale (1 = impersonal, avoided, 7 = feelings are attended to and used for problem resolution and self-understanding). The Relaxation Scale (Curtis et al., 1986) was used to measure the patients’ state of freedom, realization, and comfort (versus anxiety, drivenness on a 5-point scale). Measures of moderators: None	Immediate In-Session Outcome The degree to which the therapist passed tests was significantly and positively related to the client experiencing immediately following the therapist statement in both cases (r = .67, .62). (+ box score for plan compatible interpretation) The degree to which the therapist passed tests was significantly and positively related to the following patient relaxation in one case (r = .55). (+ box score for plan compatible interpretation)
Town et al. (2012)	24 10-minute segments from 6 adult patients with cluster C personality disorder receiving Short-term psychodynamic psychotherapy for 36- to 60 sessions (mean 47 sessions). (4 female therapists, 2 male therapists; all White). The therapist, who was the originator of the STDP, treated all patients.	Measure of therapist ER method: The PICS Psychotherapy Interactional Coding System as coded by trained judges from videotapes and transcripts has 8 categories: question, information, self-disclosure, clarification, directive, support, interpretation, and confrontation. The four content categories are: defenses, anxieties, impulse/feeling, and no content. Measure of immediate ER outcome: Affect Experiencing Scale taken from the Achievement of Therapeutic Objectives Scale (ATOS; McCullough et al., 2003), a 6-point scale (1 = no affect arousal no report of feeling, 6 = full and complete affective arousal) rated by a group of 8 judges.	Immediate In-Session Outcomes The highest predicted levels of patient immediate affect experiencing were provided by Confrontation-feeling (an average of 2.49, SD = 1.10). (+ box score) followed by confrontation-defense (M = 2.33, SD = .96) (+ box score) and then facilitative responses such as support (m = 2.39, SD = 1.10) (+ box score) and Clarification (m = 2.13, SD = 1.05). (+ box score)
Ulvenes et al. (2014)	Fifty Norwegian patients with cluster C personality disorders in the RCT receiving either 40 session CT or STDP. 19 with major depression, 19 with dysthymia, 5 with anic disorder, 5 with agoraphobia, 7 with OCD, 28 with GAD, 4 with somatoform disorder. Eight dynamic therapists and 6 CBT therapists. Therapists had about 10 years of clinical experience, had one training case, and conducted their therapy according to the treatment manuals. Eight dynamic therapists and 6 CBT therapists.	Measure of therapist ER method: Psychotherapy Q-Sort as coded by trained judges from videotapes and transcripts has 100 items. Nine items associated with Affect-focused interventions were selected to form Affect Orientation Scale such as “Th drawing attention to patient’s non-verbal behavior,” “Th sensitive to the patient’s feelings, attuned to the patient,” and “Th points out patient’s attempts to ward off feelings” Measure of immediate ER outcome: Affect Experiencing Scale taken from the Achievement of Therapeutic Objectives Scale (ATOS; McCullough et al., 2003), a 10-point scale (1 = no affect arousal no report of feeling, 10 = full and complete affective arousal) rated by a group of trained judges for every 10 min of therapy. Moderator: Patient’s sense of self which is the interpersonal sense of self and ranges from a maladaptive negative view to an adaptive positive view of the self (1 = individuals deny or ignore their wants and needs and have little or no ability to identify their strengths and weaknesses, 10 = individuals acknowledge and affirm their wants and needs and are realistic about their strengths and weaknesses).	As therapy progressed, the therapists orienting the patient to affect increasingly elicited affect (+ box score) The patients whose therapist was orienting more to affect generally exhibited more activation of affect (Between-patients level) When a therapist attempted to orient more to affect than what was normal for this particular patient (i.e., vis-à-vis the mean level of TAO for that patient), the patient exhibited more activation (within patient level). Patients who had a higher sense of self than what they started therapy with were able to experience affect when the therapist oriented them to affect more than was typical for that patient.
Nakamura and Iwakabe (2018)	Six episodes of corrective emotional experiences (CEE) taken from individual affect-focused therapy with adult patients (female = 4; male = 2) all Japanese. All patients achieved reliable change index on ER. One experienced therapist. A qualitative study	Measure of therapist ER method: Task analysis of episodes of CEE. Two researchers repeatedly watched videotaped segments and identified therapist methods to facilitate patient’s CEE. Measure of therapist ER method: Task analysis of episodes of CEEs. Two researchers watched videotaped segments and identified the essential patient steps toward the resolution of an emotional conflict from a distressed and dysregulated state to a positive emotionally regulated state.	Two groups of therapist methods were identified. One is experiential methods consisting of empathic understanding, focusing on emotional/somatic experiences, and experiential directing (+ box score). The other is relational methods consisting of affirming/valuing the client, creating/maintaining a relational focus, reciprocating disclosure, and co-creating a relational meaning. (+ box score) Patients started out from a state of secondary distress or emotional avoidance. Patients increasingly experienced and expressed more painful emotions and associated negative beliefs. Grief and self-soothing or self-compassion followed in which the patients projected warmth to themselves, which led to a sense of relief. This intrapersonal change process was followed by interpersonal change process in which the therapist and the patient shared their in-session experience. Mutual disclosure and sharing of positive emotions led to a sense of closeness and the patient articulated their experience in relation to their previous hurtful experiences.
Bentley et al. (2017)	Ten adults with NSSI (non-suicidal Self-Injuries) between 19- to 30- years old (female = 9; male = 1) (Caucasian = 6; others = 4) All had comorbidity (MDD, GAD, SOC). Four were on medication. Multiple case experiments The therapist was a master student whose adherence was monitored.	Measure of therapist ER method: Adherence was monitored during weekly supervision meetings and 20% of session audio recordings were randomly selected and rated for adherence and competency by the lead developer of the UP treatment. Average adherence rating was 4.8 out of 5 (excellent). Two modules were differentiated mindful emotional awareness and cognitive appraisal. Measure of intermediate ER outcome: The SMQ Southampton Mindfulness Questionnaire (Chadwick et al., 2008) is a 16-item self-report measure of mindful emotion awareness. Higher scores on the SMQ reflect greater levels of mindful awareness. The Emotion Regulation Questionnaire (Gross & John, 2003) is one of the most widely used research tools that classifies ER strategies into two subcategories each with 10 items: cognitive reappraisal and expressive suppression.	Nine of 10 patients demonstrated clinically reliable changes in at least one of the two emotion regulation skills. Two patients showed module specificity of change based on visual inspection of changes in mindful emotion awareness and cognitive reappraisal. six patients who received only one intervention, three showed reliable change in only the targeted skill and three showed reliable change in both skills (= box score).
Abasi et al. (2021)	Four patients with SAD with comorbidity of depression. All Iranian (female = 1; Male = 3) Multiple case experiments. Therapist was a doctoral candidate under supervision.	Measure of therapist ER method: A treatment manual for Emotion Regulation Therapy was used and the treatment adherence was monitored by weekly supervision. ERT consists of 4 modules: awareness skills, emotion regulation skills, experiential exposure to promote the new contextual learning, and consolidating gains and relapse preventions. Measure of intermediate ER outcome: Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004) is a 36-item scale that assesses 6 facets of emotion dysregulation: non-acceptance of emotional responses; difficulties in engaging in goal direction; impulse control difficulties; lack of emotional awareness; limited access to emotion regulation strategies; and lack of emotional clarity on a 5-point Likert scale. Affect Intensity Measure (AIM; Larsen et al., 1986): the AIM is a self-report 40-item measure rated on a 6-point Likert scale (never = 1 to always = 6). Negative emotional subscale was used. The Emotion Regulation Questionnaire (Gross & John, 2003) is one of the most widely used research tools that classifies ER strategies into two subcategories each with 10 items: cognitive reappraisal and expressive suppression.	ER was measured weekly using DERS, ERQ, and AIM. All four patients achieved RCI on their ER by the end of treatment. No patient showed module specificity of change based on visual inspection of changes in DERS, ERQ, and AIM. The introduction of ER skills training in the mid-phase of treatment was not associated with the increased improvement of ER skills (= box score).

Note. HCVRCS = Hill Counselor Verbal Response Mode Category System (Hill, 1985, 1986). HCVRCS-R = Hill Counselor Verbal Response Mode Category System-Revised (Friedlander, 1982).

Table II contains the coded results of the 10 studies. For all outcomes, the three authors read each study and consensually arrived at box score for each outcome: “+” denotes a positive effect, “ = ” denotes a neutral/no effect, and “−“ denotes a negative effect. We assigned +1 to a positive box score, 0 to a neutral box score, and −1 to a negative box score in order to determine an overall box score for each outcome across samples. Furthermore, in order to account for sample size differences, we then multiplied the box score by the sample size for the finding, summed across the samples, and then divided into the total sample size to get a weighted box score for each immediate and intermediate outcome. We considered scores between −1 to -.5 negative, between -.49 to + .49 neutral, and between .5 to +1 positive.

Table II. Studies included in meta-analysis of treatment distal effects on patient emotion regulation.

First author, Year	Design	Treatment Characteristics						ER Outcomes					Effect Size ^a	Association
		Disorder	Intervention	ER treatment components	Session	N		ER Measure	Pre Mean (SD)		Post/Follow-Up Mean (SD)
						Treatment	Control		Treatment	Control	Treatment	Control
Dalrymple (2007)	Open trial	SAD	ACT	Mindfulness	12 × 60-min weekly sessions	19		AAQ-9	41.21 (7.74)		33.46 (8.86)		Pre-Post d = 0.93	Earlier changes in the AAQ predicted later changes in symptom severity (β = -.48, p < .05).
											3-month 34.92 (8.91)		Pre-3-month d = 0.75
Petersen and Zettle (2009)	Random assignment	AUD	ACT vs TAU; Common therapeutic interventions (e.g., group therapy)	Mindfulness	Mean 5.2 × 30-min bi-weekly sessions	12	12	AAQ-9	44.8 (5.1)	45.5 (6.3)	34.4 (10.6)	44.1 (5.7)	ACT d = 1.32	Reductions in AAQ scores were significantly correlated with improvement on the HRS (r = .57, p = .05), but not the BDI-II (r = .32, p = . 31).
Twohig et al. (2010)	RCT	OCD	ACT vs PRT	contact with the present moment or mindfulness exercises	8 × 60-min weekly sessions	41	38	AAQ-16	59.76 (11.36)	57.16 (11.67)	73.69 (13.22)	63.81 (7.69)	Pre-Post ACT d = 1.06 PRT d = 0.47
											3-month 73.37 (14.44)	67.13 (10.74)	Pre-3-month ACT d = .86 PRT d = .64
Arch et al. (2012)	RCT	Anxiety disorder	ACT vs CBT	acceptance, mindfulness	12 × 60-min weekly sessions	57	71	AAQ-16	59.01 (12.35)	58.49 (11.84)	70.82 (13.14)	69.43 (14.75)	Pre-Post ACT d = 1.16 CBT d = 0.90
											6-month 72.14 (10.86)	6-month 68.38 (13.76)	Post-6-month ACT d = 0.63 CBT d = 0.45
											12-month 71.71 (11.42)	12-month 68.43 (11.65)	6-month-12-month ACT d = 0.10 CBT d = 0.00
Dehlin et al. (2013)	Case reports	OCD	ACT	acceptance, mindfulness	8 × 60–90-min weekly sessions	5		AAQ-II	36.2 (5.2)		21.6 (4.8)		[Pre-Post g = 2.32]	When graphed, declining AAQ-II slopes appear to generally co-occur with declines in both compulsions and avoided valued activities.
											3-month 20.6 (8.4)		[Pre-3-month g = 1.49]
Walser et al. (2015)	Open trial	Depression	ACT	acceptance, mindfulness	12–16 sessions	926		AAQ-II	30.93 (10.246)		38.92 (11.742)		[g = 0.71]	Interaction of time with experiential acceptance to predict depression severity was not significant (b = 0.05, p = .362).
Khoramnia et al. (2020)	RCT	SAD	ACT vs WL	acceptance, mindfulness	12 × 90-min sessions	12	12	AAQ-II	79.72 (9.55)	82.27 (13.10)	94.45 (7.28)	83.00 (12.73)	MANCOVA ES = 0.43 [Pre-Post g = 1.96]
											2-month 83.02 (16.46)	2-month 75.18 (15.89)	ES = 0.627 [Pre-2-month g = 1.02]
								SCS	78.18 (12.70)	84.27 (14.93)	94.81 (6.21)	81.27 (10.09)	ES = 0.38 [Pre-Post g = 2.71]
											2-month 96.77 (16.98)	2-month 83.54 (16.57)	ES = 0.435 [Pre-2-month g = 2.85]
								DERS	115.5 (13.71)	117.36 (9.78)	101.36 (9.26)	117.00 (10.86)	ES = 0.311 [Pre-Post g = 1.80]
											2-month 98.54 (15.77)	2-month 120.18 (10.60)	ES = 0.301 [Pre-2-month g = 2.40]
Roemer and Orsillo (2007)	Open trial	GAD	ABBT	a variety of mindfulness practices, diaphragmatic breathing and progressive muscle relaxation	16 × 60- to 90-min weekly to bi-weekly sessions	16		AAQ-9	44.56 (5.99)		29.81 (7.41)		univariate ANOVA ηp^2 = 0.76 [Pre-Post g = 2.04]
											3-month 34.17 (7.76)		ηp^2 = 0.58 [Pre-3-month g = 1.38]
Kumar et al. (2008)	Open trial	Depression	EBCT	mindfulness	20–24 sessions	29		AAQ-16	75.33 (13.30)		67.37 (12.94)		d = .61
Price et al. (2019)	RCT	SUD	MABT + TAU vs WHE + TAU vs TAU only (including group sessions)	developing the capacity to sustain interoceptive awareness as a mindful process to facilitate appraisal of interoceptive experiences	8–10 × 90-min sessions	74	WHE 46	DERS	87.3 (25.1)	WHE 88.2 (27.0)	77.4 (24.2)	WHE 85.7 (28.0)	[MABT vs TAU g = 0.76]
							TAU 67			TAU 83.8 (27.3)		TAU 83.6 (27.5)
Axelrod et al. (2011)	Open trial	BPD & substance dependence	DBT		60-min weekly individual sessions and 90-min weekly group sessions for 20 weeks	24		DERS	118.00 (18.47)		94.80 (17.89)		[g = 1.23]	Significant interactions were observed with frequency of substance use and emotion regulation, F(1, 21) = 8.202, p = .009, with changes in substance use losing significance when controlling for improvement in emotion regulation F(1, 21) = .112, ns.
Goodman et al. (2014)	Open trial	BPD	DBT vs healthy controls		50–60-min weekly individual sessions and 90-min weekly group sessions for 12 months	11	11	DERS	120.5 (24.2)	56.6 (14.9)	101.5 (25.7)	54.8 (14.4)	MANOVA ƞ^2 = 0.21 [g = 1.64]	Reduction in amygdala activity to repeated unpleasant pictures following DBT was associated with improved emotion regulation as measured by the change in total DERS score (r = 0.70, p < 0.02).
Bianchini et al. (2019)	RCT (a pilot study)	BPD	DBT vs TAU	core mindfulness skills, distress tolerance, emotional regulation	60-min weekly individual sessions and 120-min weekly group sessions for 12 months	10	11	DERS	56.6 (11.77)	52.9 (19.52)	65.6 (9.40)	65.1 (15.57)	[g = 0.39]
Ito et al. (2016)	Open trial	Depressive and anxiety disorders	UP		Mean 18.13 × 50- to 90-min weekly sessions	17		ERQ: Reappraisal	16.2 (6.9)		23.8 (7.7)		Pre-Post g = −0.92
											3-month 25.4 (4.9)		Pre-3-month g = −1.37
								ERQ: Suppression	13.9 (6.0)		13.8 (3.5)		Pre-Post g = 0.09
											3-month 13.4 (3.4)		Pre-3-month g = 0.15
Sauer-Zavala et al. (2016)	Case reports	BPD and comorbid anxiety and mood disorders	UP	mindfulness (present-focused and non-judgmental attention)	16–20 weekly sessions	5		DERS	112.00 (16.26)		84.40 (24.85)		ESsg = 1.29 [g = 0.83]
Beaumont et al. (2012)	Random assignment	Trauma-related symptoms	CBT + CMT vs CBT	developing empathy for themselves and acceptance of their distress	12 sessions	16	16	SCS-SF	2.13 (0.75)	1.94 (0.51)	3.72 (0.57)	3.21 (0.57)	[g = 0.66]
Wonderlich et al. (2014)	RCT	BN	ICAT vs CBT-E		21 × 50-min sessions for 19 weeks	40	40	DERS	100.6 (18.4)	98.4 (17.6)	88.9 (13.2)	90.5 (13.7)	[Pre-Post g = 0.42]
											4-moth 90.0 (13.8)	4-month 93.0 (13.3)	[Pre-4-month g = 0.58]
MacDonald et al. (2017)	RCT	ED	CBT-RR vs MI; day hospital including CBT group therapy	distress tolerance; emotion regulation	4 × 60-min weekly sessions	23	21	DERS: Nonacceptance	20.87 (6.50)	20.10 (7.17)	14.56 (4.93)	15.41 (6.34)	univariate time by condition interactions [g = 0.32]
								DERS: Goals	20.52 (5.00)	19.33 (4.76)	15.90 (4.30)	19.15 (4.31)	[g = 1.19]
								DERS: Impulse	27.57 (6.21)	27.48 (7.80)	20.55 (5.43)	24.01 (8.74)	[g = 0.53]
								DERS: Awareness	16.52 (4.57)	15.24 (4.23)	13.02 (3.99)	15.23 (4.39)	partial η^2= .16 [g = 0.99]
								DERS: Strategies	19.74 (6.05)	20.04 (7.68)	15.11 (4.77)	18.62 (6.98)	[g = 1.00]
								DERS: Clarity	20.65 (3.93)	20.71 (3.66)	15.74 (3.89)	18.88 (5.10)	partial η^2= .19 [g = 1.09]
Zalaznik et al. (2019)	Open trial	PDA	CBT	therapist encourages exploration of experiences of bodily sensations without suppression or avoidance	12 sessions	31		ERQ: Suppression	3.78 (1.29)		2.87 (1.28)		[g = 0.69]
Monell et al. (2022)	Open trial	ED	CBT or Other therapies		12-month 44% Treatment terminated 56% Treatment ongoing	307		DERS	101.80 (25.45)		87.60 (29.58)		d = −0.59	Change in emotion dysregulation primarily had an indirect effect (through change in self-image), while change in self- image had a direct effect, on change in ED psychopathology improvement.
Jain et al. (2020)	RCT	PTSD or Depression	STAIR vs TAU	emotion regulation skills, Self-compassion	5 × 60-min sessions	13	13	DERS	103.9 (21.1)	110.5 (25.4)	79.3 (17.2)	104.1 (21.4)	Pre-Post STAIR g = 1.38 TAU g = 0.30
											3-month 85.3 (19.0)	3-month 102.7 (20.2)	Pre-3-month STAIR g = 0.90 TAU g = 0.44
Doorn et al. (2014)	Open trial	Moderate to severe emotional problems	EDT	the therapist helps the patient to gradually experience more underlying feeling while regulating anxiety and reducing defensive behaviors	one 2- to 3-hour initial session	31		SCS-SF	24.88 (8.10)		27.16 (7.85)		d = 0.38
Chavooshi et al. (2017)	RCT	MUP	ISTDP online vs in-person ^b	emotional awareness, tolerate and experience emotions	16 × 60-min weekly sessions	Online 39	In-person 42	ERQ: Reappraisal	16.2 (6.5)	17.91 (6.5)	16.2 (5.7)	24.12 (4.8)	Pre-Post Online d = 0.48 In-persion d = 0.77
											12-month 15.4 (5.6)	12-month 24.1 (6.3)	Pre-12-month Online d = 0.49 In-persion d = 0.74
								ERQ: Suppression	12.3 (8.5)	11.15 (7.9)	11.9 (7.5)	5.52 (3.4)	Pre-Post Online d = 0.48 In-persion d = 0.94
											12-month 11.3 (7.2)	12-month 7.51 (3.5)	Pre-12-month Online d = 0.42 In-persion d = 0.73
Iwakabe et al. (2022)	Open trial	Transdiagnostic	AEDP	dyadic affect regulation	16 × 60-min sessions	63		DERS	94.62 (22.93)		76.97 (21.25)		Pre-Post d = −0.77
											6-month 74.13 (22.48)		Pre-6-month d = −1.03
											12-month 71.02 (21.16)		Pre-12-month d = −0.92
								SCS	15.53 (3.93)		19.44 (4.73)		Pre-Post d = 0.99
											6-month 19.98 (5.00)		Pre-6-month d = 1.32
											12-month 19.71 (4.69)		Pre-12-month d = 0.94
								AAQ-II	30.57 (6.61)		21.82 (8.24)		Pre-Post d = −1.25
											6-month 19.90 (7.74)		Pre-6-month d = −1.77
											12-month 19.75 (8.63)		Pre-12-month d = −1.46
Glisenti et al. (2018)	Case reports	BED	EFT	Phase 1: promoting awareness of emotions, welcoming and accepting emotions, putting emotions into words, identifying primary emotions Phase 2: evaluating whether the primary emotion was adaptive or maladaptive, identifying destructive emotion schemes, accessing other adaptive emotions and needs, and transforming maladaptive emotion schemes	12 × 60-min weekly sessions	6		DERS	101.23 (18.75)		53.67 (8.69)		[g = 1.66]
Normann-Eide et al. (2015)	Open trial	BPD or APD	Step-down treatment or outpatient treatment		Step-down treatment ^c: Median 45 individual session Outpatient treatment: Median 46 individual session	52		ACI: Global AC	3.58 (0.50)		3-year 4.00 (0.58)		d = 0.84	The AC change explained 7.7% of the variance in CIP (p = .033), 8.6% of the variance in Identity Integration (p = .026), and 8.7% of the variance in Relational Capacities (p = .005) at 3-year.
Mennin et al. (2018)	RCT	GAD	ERT vs MAC	patients were encouraged to deploy regulation skills during in-session and out-of-session exposures	20 × 60- to 90-min weekly sessions	28	25	ERQ: Reappraisal	22.6 (6.2)	21.6 (9.2)	Mid 26.4 (5.2) Post 29.7 (4.4)	Mid 21.6 (9.7) Post 24.0 (9.9)	g = 0.54	All proposed mediators showed an indirect effect of group on the primary outcomes. For example, GAD CSR was mediated by ERQ Reappraisal (B = -.27, p < .05) and DERS (B = -.39, p < .05).
								DERS	98.2 (23.1)	104.8 (22.4)	Mid 82.3 (20.3) Post 74.6 (19.0)	Mid 102.2 (23.2) Post 96.0 (22.0)	g = 0.80
O'Toole et al. (2019)	Open trial	GAD	ERT	the cultivation of emotion regulation skills	16 × 60- to 90-min weekly sessions	31		ERQ: Reappraisal	20.8 (7.8)		29.2 (7.3)		d = 0.9	Changes in cognitive reappraisal temporally preceded changes in all three outcomes (PSWQ, z = −2.37, p = .018, r = .42; STAI-7, z = −2.43, p = .016, r = .43; GAD-7, z = −2.19, p = .029, r = .39).

Note. ER: Emotion Regulation.

Disorder: SAD; Social Anxiety Disorder; AUD; Alcohol Use Disorder; OCD; Obsessive Compulsive Disorder; GAD; Generalized Anxiety Disorder; SUD; Substance Use Disorder; BPD; Borderline Personality Disorder; BN; Bulimia Nervosa; ED; Eating Disorder; PDA; Panic Disorder with Agoraphobia; PTSD; Posttraumatic Stress Disorder; MUP; Medically Unexplained Pain; APD; Avoidant Personality Disorder; BED; Binge-Eating Disorder.

Intervention: ACT: Acceptance and Commitment Therapy; TAU: Treatment As Usual; PRT: Progressive Relaxation Training; CBT: Cognitive Behavioral Therapy; WL: Waiting List; ABBT: Acceptance-Based Behavior Therapy; EBCT: Exposure-Based Cognitive Therapy; MABT: Mindful Awareness in Body-oriented Therapy; WHE: Women’s Health Education; DBT: Dialectical Behaviour Therapy; UP: Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders; CMT: Compassionate Mind Training; ICAT: Integrative Cognitive-Affective Therapy; CBT-E: Cognitive-Behavioral Therapy-Enhanced; CBT-RR: Cognitive Behavior Therapy for Rapid Response; MI: Motivational interviewing; STAIR: Skills Training in Affective and Interpersonal Regulation; EDT: Experiential Dynamic Therapy; ISDP: Intensive Shortterm Dynamic Psychotherapy; AEDP: Accelerated Experiential Dynamic Psychotherapy; EFT: Emotion-Focused Therapy; ERT: Emotion Regulation Therapy; MAC: Modified Attention Control.

Outcome measure: AAQ: Action and Acceptance Questionnaire; SCS: Self-Compassion Scale; DERS: Difficulty in Emotion Regulation Scale; ERQ: Emotion Regulation Questionnaire; SCS-SF: Self-Compassion Scale-Short Form; ACI: Affect Consciousness Interview; HRS: Hamilton Rating Scale; BDI-II: Beck Depression Inventory-II; CIP: Circumplex of Interpersonal Problems (A 48-item version of the Inventory of Interpersonal Problems); CSR: Clinician’s Severity Rating from the Anxiety Disorders Interview Schedule for DSM-IV; Lifetime Version, PSWQ: Penn State Worry Questionnaire; STAI-7: State Trait Anxiety Inventory-7; GAD-7: Generalized Anxiety Disorder-7.

^a Effect sizes shown in [] were calculated by the authors.

^b This meta-analysis used in-person data only.

^c 18-week day-hospital treatment and then 90-min weekly group therapy for a maximum of 4 years and weekly individual therapy for a maximum of 2.5 years.

For immediate outcomes, we first looked at five studies of client experiencing. In two studies of short-term psychodynamic therapy, plan-compatible interpretations were associated with the higher level of client experiencing (Silberschatz et al., 1986; Silberschatz & Curtis, 1993). Similarly, in client-centered therapy, interpretations referring to feelings given with particular nonverbal qualities were associated with a higher level of experiencing (Gazzola & Stalikas, 1997). In Hill et al. (1988), however, interpretations did not have a higher experiencing level compared to other response modes such as self-disclosure, open question, and approval. Similarly, Stalikas and Fitzpatrick (1996) did not find a significant relationship between therapist response modes and the client experiencing. There were thus three positive and two neutral box scores. The weighted box score across these five studies was .50 for interpretations on ER as measured with the client experiencing scale.

We also examined three short-term dynamic psychotherapy studies of therapist affect-oriented skills including confrontation on affect, defenses, and facilitative/supportive methods (Town et al., 2012) and focusing on affects (Ulvenes et al., 2014) in association with adaptive affect. Therapist focus on affect was associated with a higher level of adaptive affect experiences, which is a part of ER via emotional transformation. In a qualitative study, Nakamura and Iwakabe (2018) found that the immediate outcome of experiential methods was arriving at an emotional resolution. For these three studies, there were three positive box scores; the average weighted box score was 1.

In terms of intermediate outcomes, Bentley and colleagues (2017) tested the introduction of mindful emotional awareness skills and emotion modulation skills related to improvements in specific areas of ER (The Southanmpton Mindfulness Questionnaire for mindful emotional awareness and The Emotion Regulation Questionnaire-Reappraisal Subscale for emotion modulation) in the Unified Protocol. The result showed no module-specific effects. Abasi et al. (2021) studied four cases of Emotion Regulation Therapy for social anxiety disorder in which the introduction of ER modulation skills component had an additive effect to the mindful emotional awareness component that was initially given. They used the acceptance subscale of Difficulties in Emotion Regulation Scale for emotional awareness, the Affect Intensity Measure for emotional modulation, and Reappraisal subscale of the Emotion Regulation Questionnaire for adaptive emotion regulation strategy for every session. Neither study found module-specific effects, though most patients achieved reliable change by the end of the course of treatment on these emotion regulation scales as well as their symptoms for social anxiety. Box scores for module-specific outcome are neutral for three emotion regulation scales.

In sum, immediate outcomes (client experiencing and activating affect) were positive, indicating that interpretations focusing on immediate feelings with gentle and tentative manner of delivery and focusing on the patient immediate emotional experience resulted in a higher level of experiencing and adaptive affect. The experiencing level, however, does not specifically tell us about what aspects of emotion regulation is at work. On the other hand, Nakamura and Iwakabe (2018) showed that the process of emotional change leading to a regulated emotional state may involve qualitative shifts from secondary emotions which are symptomatic emotional distress such as helplessness, anxiety, and feeling hurt, via more painful emotions to grief and self-compassion, followed by positive emotional experience with the therapist. This finding suggests that ER involves overcoming avoidance and defenses to allow distressing emotions, facing more difficult and painful emotions, allowing of underlying adaptive emotions and reflecting on emotional experience in the therapeutic relationship.

In contrast, no module specific effects of mindful emotional awareness or emotion modulation skills were found in studies on intermediate outcomes, though they were effective in improving ER. Bentley et al. (2017) suspected that different therapist methods may address the extinction of distress in response to intense emotions. They also suggested that individuals respond differently to different treatment modules.

ER and Distal Treatment Outcomes

From the search strategy detailed above, 28 independent studies encompassing a total of 1034 patients and 201 therapists (the number of therapists was not cited in 10 studies) were included in the meta-analysis of distal outcomes. The main characteristics of the 28 included studies are summarized in Table II. The data on which our analysis is based span over 15 years (2007–2022) and consist of published studies using independent samples collected in naturalistic settings (k = 18) and RCTs (k = 10). The number of eligible studies (k = 28) included in this meta-analysis is smaller than the size of previous meta-analyses because we included only individual treatments with clinical samples. ACT (k = 7), DBT (k = 3), and UP (k = 2), were the most commonly employed treatment packages. These therapies had some group components (k = 7) in addition to individual therapy. Although one study compared online intervention with in-person intervention, we included only the in-person data in this meta-analysis. A variety of psychological disorders and problems were treated, including anxiety disorders, eating disorder, borderline personality disorder, and substance use disorder.

The most frequently used outcome scales were DERS (k = 13), AAQ (k = 10), and ERQ (k = 5). Although they measure somewhat different aspects of ER, we combined them in one analysis given that moderate to high correlations have been reported among them. We report both overall mean scores and subscale means when they were available (Table II). For the meta-analysis, we used effect sizes for the full scale unless specified.

We conducted a series of random effects models. This model is based on the assumption that the studies in this meta-analysis were randomly sampled from a population of studies. All analyses were conducted using Comprehensive Meta-Analysis (Borenstein et al., 2013). First, we tested an overall pre-and post-treatment difference in ER. Second, we examined potential moderators –whether effect sizes systematically varied due to (a) measures, (b) types of treatments, (c) types of control group, and (d) type of disorder. In addition, comparisons between the treatment group and different control groups were tested when available. Treatment effect was estimated using the weighted mean effect size Hedges’ g.

The random effects model with all 28 independent studies resulted in a large treatment effect (g = 0.82, 95% CI [0.71, −0.93], p < .001) compared to no treatment/wait list. That is, multiple therapies evidenced large improvements in patient ER compared to no treatment or pre to post treatment. At the same time, there was a large heterogeneity in the effect sizes, I² = 82.66% (Q = 155.68, df = 27, p < .001).

We also calculated the effect size of pre-treatment to 2-to 6-month follow-up for the 10 studies that reported those data (g = 0.86, 95% CI [0.59, −1.14], p < .001; I² = 74.06; Q = 34.69, df = 9, p < .001) and pre-treatment to 12-month follow-up for 3 studies (g = 0.71, 95% CI [0.26, −1.15], p = .002; I² = 89.37; Q = 18.81, df = 2, p < .001). The results indicate that treatment gains in ER were largely maintained; there was no significant deterioration from post-treatment to 2- to 6- and 12-month follow-up (for 2- to 6-month, k = 10; g = −0.07, 95% CI [−0.26, - 0.12], p = .456; I² = 58.02; Q = 21.44, df = 9, p = .011; for 12-month, k = 3; g = 0.03, 95% CI [−0.29, - 0.35], p = .871; I² = 83.12; Q = 11.85, df = 2, p = .003). Although the number of studies with the follow-up data was small, the treatment effect on ER was maintained after termination.

The fail-safe N indicated that approximately 6811 studies with an effect size of zero would be need to be published in order to bring the weighted mean effect below .10, or practical significance. We also calculated Duval and Tweedie’s trim and fill. The adjusted effect size for a random effects model was g = 0.71 (observed value g = 0.82, 95% CI [0.60, - 0.83]). All our data are based on a search of electronic databases and included only published articles, which may have resulted in bias toward larger N studies and positive effect sizes. Figure 2 presents a funnel plot, which is a diagram of standard error on the Y axis and the ES on the X axis.

Figure 2. Funnel plot of treatment effects on emotion regulation outcomes.

Given the large heterogeneity in effect sizes, we conducted a series of moderator analyses. The moderator analyses related to the ER measure, therapy type, comparison group, and patient type were all statistically significant. The effect sizes for each ER measure are presented in Table II. The effect sizes for the DERS, AAQ, and SCS as outcome measures were similar (from 0.86 to 0.97), whereas effect sizes for the suppression subscale in ERQ were significantly smaller in comparison (g = 0.49). Table III also shows the average effect sizes for the psychological treatments on the ER outcome. ACT (k = 7; g = 0.95) and DBT (k = 3; g = 1.11) had slightly larger effect sizes than CBT and UP, but all were moderate to large effect sizes. The effect size comparing the ER treatment against active control (k = 9) was g = 0.67 (95% CI [0.39, −0.94], p < .001). Compared to waiting list group, the effect size was significantly larger (k = 3; g = 1.51, 95% CI [0.85, −2.18], p < .001). For the 16 studies with no control group, the effect size was also large (g = 0.83, 95% CI [0.70, −0.96], p < .001).

Table III. Effect sizes by outcome assessment timet, ER measure, treatment package, control group, disorder.

Comparison	Number Studies	Hedges's g and 95% confidence interval				Heterogeneity
		Point estimate	Lower limit	Upper limit	P-value	Q-value	df (Q)	P-value	I-squared
Time Point
Pre-Post	28	0.82	0.71	0.93	<.001	155.68	27	< .001	82.66
Pre-2- to 6-month follow-up	10	0.86	0.59	1.14	<.001	34.69	9	< .001	74.06
Pre-12-month follow-up	3	0.71	0.26	1.15	.002	18.81	2	<.001	89.37
Post-2- to 6-month follow-up	10	−0.07	−0.26	0.12	.456	21.44	9	.011	58.02
Post-12-month follow-up	3	0.03	−0.29	0.35	.871	11.85	2	.003	83.12
ER measure
AAQ	10	0.97	0.70	1.24	<.001	60.75	9	<.001	85.18
DERS	13	0.96	0.74	1.19	<.001	82.11	12	<.001	85.39
ERQ-Reappraisal	4	1.00	0.81	1.19	<.001	0.99	3	.804	0.00
ERQ-Suppression	3	0.49	0.08	0.90	.020	10.94	2	.004	81.72
SCS	4	0.86	0.35	1.38	.001	25.51	3	<.001	88.24
Treatment package
ACT	7	0.95	0.57	1.32	<.001	33.46	6	<.001	82.07
DBT	3	1.11	0.54	1.67	<.001	4.55	2	.103	56.03
UP (ERQ-Combined and DERS)	2	0.66	0.34	0.98	<.001	1.20	1	.273	16.95
UP (ERQ-Reappraisal and DERS)	2	0.90	0.60	1.21	<.001	0.25	1	.619	0.00
CBT	3	0.56	0.40	0.72	<.001	2.83	2	.244	29.19
ERT	2	1.07	0.78	1.37	<.001	0.01	1	.909	0.00
Experiential (EDT, ISTDP, AEDP, and EFT)	4	0.87	0.47	1.26	<.001	25.29	3	<.001	88.14
Control
Active control	9	0.67	0.39	0.94	<.001	18.71	8	.016	57.24
Waiting list	3	1.51	0.85	2.18	<.001	4.00	2	.135	50.03
No control	16	0.83	0.70	0.96	<.001	121.56	15	<.001	87.66
Disorder
Depression/Anxiety	10	0.82	0.60	1.05	<.001	42.16	9	<.001	78.65
OCD	2	1.46	−0.09	3.01	.064	8.21	1	.004	87.82
PD	5	0.93	0.61	1.26	<.001	16.04	4	.003	75.06
ED	4	0.81	0.34	1.27	.001	17.44	3	.001	82.80
SUD	2	0.85	0.47	1.23	<.001	1.15	1	.283	13.14

ER: Emotion Regulation; AAQ: Action and Acceptance Questionnaire; DERS: Difficulty in Emotion Regulation Scale; ERQ: Emotion Regulation Questionnaire; SCS: Self-Compassion Scale; ACT: Acceptance and Commitment Therapy; DBT: Dialectical Behaviour Therapy; UP: Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders; CBT: Cognitive-Behavioral Therapy; ERT: Emotion Regulation Therapy; EDT: Experiential Dynamic Therapy; ISDP: Intensive Shortterm Dynamic Psychotherapy; AEDP: Accelerated Experiential Dynamic Psychotherapy; EFT: Emotion-Focused Therapy; OCD: Obsessive Compulsive Disorder; PD: Personality Disorder; ED: Eating Disorder; SUD: Substance Use Disorder.

The psychological treatments were more effective for depression and anxiety (k = 10; g = 0.82, 95% CI [0.60, −1.05], p < .001), personality disorder (k = 5; g = 0.93, 95% CI [0.61, −1.26], p < .001; mostly of borderline personality disorder), and substance use disorder (k = 2; g = 0.85, 95% CI [0.47, −1.23], p < .001) than eating disorder (k = 4; g = 0.81, 95% CI [0.34, −1.27], p = .001). The number of sessions (g = −0.001), year of publication (g = 0.006), the number of participants (g = −0.00) bore no systematic relation to the ER effect sizes (p > .33).

Possible Negative Effects and Harm

Therapists using affect-focused methods to activate or evoke strong emotions need to be cautious when working with patients with impulse control problems, active substance abuse, and those whose dysregulation is exacerbated due to organic factors, including thought disorders (Greenberg, 2015). Individuals suffering from these disorders may not contain strong emotions and as a result act out on them. Affect-focused methods may not lead to patient’s productive emotional experience when patients are feeling negative toward the self, such as shame, guilt, and self-contempt (Ulvenes et al., 2014).

There has been no evidence that suggests that ER methods lead to higher risk for dropouts and negative effects than psychotherapy methods that do not directly focus on or evoke emotional experience. Nonetheless, future studies need to identify patient characteristics that are associated with non-improvement and deterioration.

Limitations of the Research

Few studies have examined therapist moment-to-moment methods and their immediate, in-session and intermediate effects on patient ER. Virtually all studies have examined the effects of multicomponents treatment packages on distal ER outcomes. The overall treatments prove effective in enhancing ER, but we do not know which specific components or methods account for the improvement. Affect-focused methods and structured methods are quite different. Common and different change processes according to each method should be delineated.

Another important task is to define ER and its multiple facets. There are several similar concepts, such as emotional processing and emotional experiencing, and their differences as well as overlaps have not yet been empirically delineated.

Future researchers can also examine the therapeutic relationship in ER work. Implicit ER is hypothesized to develop through internalizing an empathic therapist. One study showed that patients with therapists who had higher ER ability had significantly better improvements in emotion regulation (Abargil & Tishby, 2021). Future researchers could also examine common and unique factors associated with ER methods of different orientations in the context of particular therapeutic relationships.

The vast majority of studies in our meta-analysis were conducted in the United States among samples of predominantly White individuals. Ethnoracial status, gender differences, socioeconomic status, and other cultural identity factors have not been adequately examined.

The measurement of ER as an outcome has mostly been conducted using self-report scales; however, they may not capture the variability in how individuals spontaneously select and implement ER strategies (Aldao, 2013). Self-report questionnaires tend to overlook natural fluctuations of ER in response to daily environmental demands and emotional experiences. They are also subject to recall bias and do not necessarily correspond to the concurrent report of ER (Aldao et al., 2010; Solhan et al., 2009).

An alternative to the self-report scales is ecological momentary assessment, a set of techniques that utilize repeated sampling of individuals’ real-time behaviors by the use of mobile and internet technology (Shiffman et al., 2008). This might identify how a particular therapist method can affect patient’s ER in their daily life. In addition, the moment-to-moment measure of ER can be used to test the immediate effect of therapist methods and relationship behaviors. Common autonomic and electromyographic measures may be used to track physiological arousal (Zaehringer et al., 2020). Motion energy analysis (Ramseyer, 2020) using an automated computer program may be also an effective way to track emotion regulation in the moment-to-moment manner. Nonverbal synchrony, or the coordination of patient’s and therapist’s bodily movement, has been shown to be associated with psychotherapy outcome and also with emotion regulation (Tschacher et al., 2014). Considering that ER occurs dyadically (Fosha, 2001), a combination of these measures may detect microprocess of therapist method and relational behaviors.

Training Implications

Given the meta-analytic evidence that multiple psychological treatments lead to improvement in ER for a range of psychological problems, trainees could benefit from learning about ER as well as its therapeutic methods. Students may learn to use observer rating scales to identify in-session markers for ER. They also can learn methods to increase emotional awareness, identify emotional avoidance, modulate dysregulated emotions, and transform maladaptive emotions with adaptive emotions as these are frequent components of ER work.

We suspect that deliberate practice might prove helpful in mastering affect-focused methods and related skills (Goldman et al., 2021). The therapist’s use of voice and nonverbal behavior is critical in communicating empathy (Abargil & Tishby, 2021) and helping patients modulate their emotions (Paivio & Laurent, 2001). Trainees can practice these responses while focusing on their voice and nonverbals associated with ER, repeatedly watch their performance, receive feedback from supervisors, incorporate it, and practice the skill until it is mastered. One of the components of deliberate practice training is the acquisition of inner skills for trainees to regulate themselves. Working with dysregulated patients can arouse strong emotional reactions in therapists. Trainees need to develop their emotional capacity to be aware of their own emotional state, stay empathically attuned to their patients, and adjust their verbal and nonverbal responses. In most affect-focused therapies, videotaped supervision is the norm in which both supervisor and supervisee track the moment-to-moment emotional process and formulate therapist responses that are most facilitative of emotional change (e.g, Greenberg & Tomescu, 2017; Prenn & Fosha, 2017).

Finally, trainees can benefit from receiving training in treatments focusing on ER. ACT, AEDP, DBT, and EFT demonstrated larger effect sizes on ER in our meta-analysis. Specific instructions for structured exercises and homework will be helpful tools for trainees working with patients with emotional dysregulation.

Therapeutic Practices

The meta-analysis demonstrated large gains in patient ER from psychological treatments, but empirical evidence is lacking on the effectiveness of specific components or therapist methods. Hence, we offer recommendations based on the sparse research evidence and our clinical practice:

• Enhance patient ER capacity for a variety of behavioral disorders.

• Use either affect-oriented methods or structured psychoeducational and skill training methods to work with ER.

• Employ steps associated with enhancing patient ER: undoing experiential avoidance, enhancing emotional awareness, promoting a full emotional experience, understanding the meaning of experience, and learning strategies to cope with distress.

• Provide a therapeutic relationship characterized by empathy, validation, and support to help patients develop ER capacity. Such a relationship is frequently internalized by the patient and may function to change schemas that are putatively at the root of emotional dysregulation.

• Address patients’ fearful avoidance or suppression of emotional experience via psychoeducation.

• Consider the patient’s sense of self in focusing on ER in session: When patients are in their negative self-state, they frequently do not recognize positive aspects of themselves and focusing on emotion is not likely to bring adaptive affects.

• Consider the patient’s cultural identity and worldview as well as the context in which the patient’s emotional experience occurs in evaluating the appropriateness of ER.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by JSPS [grant number 22K03119].

Notes

1 The clinical material presented here was gathered in compliance with the APA ethics code and a written consent from the patient was obtained. The original material was modified for brevity.

2 The case material was fictitious clinical amalgams for the sake of clinical illustration by the authors.